Acute Gastroenteritis (AGE) in Children

Evidence Based Guidelines for AGE in children We see and treat acute gastroenteritis (AGE) in the pediatric ED every day. For most, oral rehydration therapy after ondansetron (ORTAZ) is the mainstay of treatment. In fact, a meta-analysis looking at oral rehydration solution (ORS) and traditional IV hydration showed only a 3-4% failure rate of ORS. Here are a few evidence-based pearls and pitfalls to guide your management.

2. “The triage note says the patient is here for nausea/vomiting/diarrhea. I will wait until after an initial PO trial before I order medications.” In order to promptly treat nausea/vomiting due to suspected AGE, we are obviously going to institute ondansetron Ondansetron has a good safety profile at appropriate doses. The overwhelming majority of children will only have mild to moderate dehydration and should be rehydrated with a balanced ORS only. Giving juice or soda (high glucose, minimal sodium) may worsen an already existent osmotic diarrhea. IV fluids are indicated only in severe dehydration or in children who are unable to take ORS enterally.
3. “I didn’t find out that the patient had hypoglycemia until the electrolyte panel came back.” If you are starting IV hydration in a child that you suspect has severe dehydration, point-of-care glucose testing should be performed rather than waiting for the formal metabolic panel. Young children have low glucose reserves and can easily develop hypoglycemia when they are dehydrated. Hypoglycemia should be treated promptly.
4. “My patient bounced back 2 days later with severe dehydration. She looked great when I discharged her. I thought the parents would know what to bring her back for.” Avoid the assumption that parents know signs of dehydration. Counsel them that if symptoms persist, they must be able to replace the fluid losses and also give maintenance fluids. If they cannot, they should return to the ED. Probiotics can be prescribed or recommended for children with AGE early in the course of their illness. This may help decrease the duration of their diarrhea by approximately 24 hours and could decrease the need of further interventions and medications.
5. “I prescribed azithromycin for my patient who had diarrhea for the last 4 days because I was afraid she might have a bacterial infection.” In all well-appearing children and most ill children, antibiotics should not be started until there is confirmation of a bacterial pathogen in the stool via stool culture or C.diff assay. Initiating antibiotics may unnecessarily harm the patient. Do not forget to ask about a history of recent travel, drinking from fresh water streams/lakes, and recent antibiotics use.

source: ebmedicine.net

Commonly tested board topic:

Bacterial gastroenteritis -> E.Coli O157:H7 (Shiga like toxin) -> hemolytic uremic syndrome -> microangiopathic hemolytic anemia (schistocytes), renal failure, thrombocytopenia -> Tx is to avoid abx, supportive, transfusion/plasma exchange if indicated, eculizumab if CNS involvement.

source: RoshReview

Today's pearl - Spinal Cord Syndromes

Developing para/quadriplegia as a result of a spine injury is a devastating event. Such injuries place an enormous emotional, social, and financial burden on the individual and society. Remember there is only meager evidence that steroids improve acute spinal cord injury (ASCI) outcomes in any meaningful way (see NASCIS trials). Until better therapies are developed (perhaps through stem cell research), there is currently no ideal treatment for ASCIs. Until future therapies are developed, the best approach is to prevent, identify, and repair existing spine fractures before injury to the spinal cord occurs. Through the use of judicious immobilization, clinical judgment aided by clinical decision instruments and the use of radiography, the astute emergency physician will identify these spine fractures. This will prevent secondary cord injury, allowing early surgical repair. Source: Ebmedicine.net

Spinal cord syndromes are usually the result of conditions extrinsic to the spinal cord, such as: compression due to spinal stenosis, herniated disc, tumor, abscess, and trauma (i.e. hematoma, retropulsion of bony fragments, bullet/knife injury).

Less commonly, disorders intrinsic to the cord, such spinal cord infarction or hemorrhage, transverse myelitis, viral infection (HIV, polio, West Nile), syphilis, vitamin/mineral deficiency (B12, copper), decompression sickness, lightning injury, radiation therapy, syrinx, and neoplasms can also lead to the characteristic syndromes highlighted below.

Lastly, we must not forget about the commonly tested synaptic diseases that may present with a variable degree of weakness and/or sensory findings. Consider these zebras in your differential: tick bite paralysis, MG, Lambert Eaton Syndrome, Guillan-Barre, and Botulism.

1. Transverse cord lesion – Can be caused by hemisection of the cord usually in the setting of penetrating trauma. Results in loss of all function (vibration/proprioception, pain/temperature) below the level of the injury.
2. Hemicord lesion a.k.a. Brown-Sequard’s paralysis - resulting in loss of motor and proprioception below the ipsilateral side as the injury or lesion, and loss of pain and temperature sensation below the contralateral side as the lesion. Note patients will have loss of pain and temperature sensation on the ipsilateral side at the level of the lesion as well given the crossing of the fibers in the cord.
3. Central cord lesion (most common) – typically from a hyperextension injury. Results in upper extremity motor and sensory loss in a cape-like distribution. Syringomyelia can also cause this but classically presents as loss of pain/temperature sensation in a cape-like distribution only.
4. Central cord syndrome – Same as above but larger. Devastating injury, complete paralysis. Sacral sparing may occur.
5. Posterior cord syndrome – A common result of a hyperextension injury. Also, classically “Tabes Dorsalis” from syphilis and “Subacute Combined Degeneration” from B12 Causes loss of vibration and position loss below the level of the lesion, and affects the lateral cords in B12 deficiency leading to further sensory loss. Don’t forget to do a Romberg test!
6. Anterior cord syndrome – Usually caused by ischemia to the anterior spinal artery (ASA) or post AAA repair, or flexion injury such as diving injury at C5-C7. Results in motor function and pain/temperature loss below the level of the lesion. Worst prognosis.

Pearl of the day - New York State Communicable Disease Reporting

In general, reporting the following is mandated by law in all or most states Reporting Requirements

• Communicable diseases
• Child abuse
• Elder abuse
• Domestic violence: however, victim can refuse reporting in most states
• Most states: GSWs

Note that failure to report may lead to penalties/civil liability.

In New York State specifically, the following communicable diseases are reportable to the DoH (table). Have the contact center page the local health department or to obtain reporting forms (DOH-389), call (518) 474-0548. Cases of HIV infection, HIV-related illness and AIDS are reportable on form DOH-4189 or by calling (212) 442-3388.

Sources: NYS DoH, RoshReview